Mueller, Dora �. SLID
NEW YORK STATE DEPARTMENT OF HEALTH`
Vital Records Section Burial - Transit Permit
Name Frst ,middle st Se
Uor� 1" tjeiie ' -
Date of Death Age If Veteran of U.S. Armed Forces,
0 3. - NC) " f -tl i� 7 War or Dates NI()
Place of Death e (( ,l Hospital, Institution or t ,j
Z CityW. , Town or Village J C41 Y-0O N Street Address O j y d. � 0 7
Manner of Death (.Natural Cause 0 Accident 0 Homicide 0 Suicide Undetermined Pending
LtiY�311 Circumstances Investigation
ill Medical Certifier illeame, i Title
Address 3
Death Certificate Filed e^ Register Number
ini City, Town or Village , Csf7 Y`0 0 0 ig_6
3
5.1❑Burial Date -- Ce ,tery or Crematory ,_
['Entombment Address
-,�Ci - /-5 rVut el) C,� ,I r ekt,ne ov y
Address
emation gt;ee►.)a hU1-y I'v-
Date / Place Reri oved
Z El Removal and/or Held
and/or Hold Address
t
0 Date Point of
Transportation Shipment
Cl by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Mi Permit Issued to i
na)
Registration N mber
Name of Funeral Home /� -tf(- J �, 14 P p trA/ f0m-e— 0'0J5/1
Address l U i 1 9 s f i--e-0-%- /-h 1,/ e-_
pi Name of Funeral Firm Making Disposition or to Whom
14 Remains are Shipped, If Other than Above
2 Address
IM
lit
P` Permission is hereby granted to dispose of the human re ins described above as indicated.
Date Issued Oa-,�� gd/S Registrar of Vital Statistics a 7-
(signature)
District Number i 31,3 Place CJL t- A._ �17:
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
iii Date of Disposition 112.3)1S Place of Disposition Ct)1_.) 6 ,,.,..
2 (address)
tti
U)
CC (section) V of number) r, (grave number)
taName of Sexton or Person jn Charge of Premises lh-'• ` "*1-
z L/ (ple a print)
W.
Signature •4— Title trikAN"
(over)
DOH-1555 (02/2004)